Action Points

Note that these AHA blood pressure recommendations thematically echo recent guidelines that have "loosened" blood pressure targets in various subgroups.

Be aware that, per the guidelines, the BP target for individuals over 80 should be 150/90.

Treatment should target under 140/90 mmHg for most hypertensive patients with known coronary artery disease (CAD), according to a new statement from the American Heart Association (AHA), the American College of Cardiology (ACC), and the American Society of Hypertension (ASH).

The last AHA recommendations in 2007 had advocated more aggressive targets of 130/80 mmHg in patients with a history of stable angina or acute coronary syndromes and of 120/80 mmHg in left ventricular dysfunction.

The update still suggested that under 130/80 mmHg could be a target, albeit with a lower level of evidence, for certain higher risk groups such as those after a heart attack, stroke, or transient ischemic attack, peripheral arterial disease, or abdominal aortic aneurysm.

Another exception was for CAD patients over age 80, for whom the goal was 150/90 mmHg, Clive Rosendorff, MD, PhD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues wrote online in Hypertension and the journals of the other organizations.

There has been a real shift over the past 20 years away from "as low as possible" as a treatment target, noted co-author Suzanne Oparil, MD, director of the vascular biology and hypertension program at the University of Alabama at Birmingham.

Overall, the various available guidelines on hypertension management have been coming to a consensus that 140/90 mmHg is appropriate for most people, she told MedPage Today.

"The similarities if you look at all the guidelines around the world are bigger than the differences," she said.

However, even looser recommendations -- commonly but unofficially known as the Eighth Joint National Committee (JNC 8) -- from a group Oparil co-chaired had stirred a great deal of controversy for a few such differences.

Those 2014 recommendations eased the goal to 150/90 mmHg for people 60 and older and to 140/90 mmHg for people with diabetes or chronic kidney disease. For everyone else, the goal was to be 140/90 mmHg regardless of history of heart disease.

While there was agreement with the 2007 AHA statement’s prevention target of 140/90 mmHg for the general population, it created confusion, according to AHA president Elliott Antman, MD, of Brigham and Women's Hospital in Boston, who was not on the writing committee.

"The writing committee reinforces the target of less than 140/90 to prevent heart attacks and strokes in patients with hypertension and coronary artery disease," he said in a statement. "This is important since confusion has arisen in the clinical community over the last year regarding the appropriate target for blood pressure management in the general population."

The new update considered a wider range of evidence, including observational findings, meta-analyses, and data outside the randomized trials with hard cardiovascular event endpoints that were the sole basis for the 2014 guidelines. But many of the randomized trials into blood pressure thresholds excluded patients with pre-existing heart disease, she pointed out.

"Both guidelines are good, but they're sort of applicable to different populations of patients and different populations of providers," Oparil suggested.

The update cautioned that, for patients with coronary artery blockages, blood pressure should be lowered slowly without dipping below 60 mmHg diastolic, particularly in patients more than age 60.

In terms of antihypertensive drugs, the update aimed to clear up confusion over the role of beta-blockers, Rosendorff told MedPage Today.

"In uncomplicated hypertension, beta-blockers don't have a big role to play because they are less effective than other classes of drugs in preventing cardiovascular complications," he said. "However, in patients with established coronary artery disease, beta-blockers move from limbo to center stage.

"Beta-blockers should be included in drug treatment of hypertension in patients with established coronary artery disease."

Whatever strategy one uses, don't forget that the treatment thresholds and goals are only recommendations based on imperfect evidence, Oparil added.

More high-quality data to determine the appropriate goal for high-risk groups over age 50, including those with heart disease, should be coming from the randomized SPRINT trial, she noted. SPRINT is sponsored by the National Heart, Lung and Blood Institute.

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